In this use case, we will show how to setup outbound data transfers to Customers in Adeptia Connect. Suppose a Claims Processing Company needs to send Claims Data to its Recipients which are Insurance Carriers. As part of its service offerings to Insurance Carriers, the Claim Processing Company validates the claims (HIPAA 837 and non-EDI X12 formats) and sends out the validated claims as outbound data to the specific Insurance company which owns the insurance policy.
Outbound file includes important attributes that the Insurance company would need in order to pay out the claim to the individual. Some of these attributes include Recipient Number, Claim Number, Insured Policy Number, Policy Effective Date, Policy Expiration Date, Coverage Code, Carrier Number, Carrier ID among other data fields.
For the business team, there are two important features we would like to focus in this example. First, ability to extract data from multiple different data sources/tables from a common data model. Second, ability to schedule the outbound transaction to send out the particular Claims, selected in the first step, to the Insurance Carrier (Recipient).
Setting up Outbound Data Transfer as part of Transaction Configuration
A simpler approach of setting up an outbound data transfer is through configuring an Outbound Transaction. First thing that user has to take into account is the data source that is needed to extract and build an output file. In the Source configuration part, user can select Database as a Source system and then select the particular database schema needed to extract the data from the source tables. Here the IT Team pre-defines the Database source/schema and business user simply selects the Recipient from a drop-down list, as shown below.
Business User selects the Recipient Data Source from a drop-down
After selection of the Claims data for a particular Recipient and the applicable Mapping to convert data into a required output format, User also needs to provide the routing rule that identifies who should receive the file once it is generated. Here the routing rule is based on the file name that contains the Recipient ID. If the Recipient ID in the output file name is ZURICHINS then the system will automatically route the file to the Recipient. Here is a screenshot of the routing rule condition set in the Transaction.
Example of a Routing rule based on File Naming convention
Adeptia Connect provides two options for Routing files.
- Context based routing – Routing of files based on its name to a correct recipient
- Content based routing – Routing based on some content within the output file
For more information, refer to Defining a File Outbound Template
Final step to define the Outbound Data Transfer is to select the transfer mode on how to send the file to a Recipient. User can select from a list of connectors and applications such as SFTP, Dropbox, AS2, REST API, etc.
List of available Application Connectors to send files to Recipients
Setting up Outbound Data Transfer Rules through Custom Web Forms
This approach requires a custom Web Form development which is also supported in Adeptia Connect. Let’s go through data selection options that are available to the business users to extract data from the backend Claims database. A custom Web Form provides the extraction, sorting, filter conditions to a user so that a Recipient’s data can be selected from the Claims database. In this option, the IT team designs a Web Form that is tied to backend APIs and process flows that help users filter/search specific Recipient(s), identify additional Policy parameters in order to build a Claim file. Below is an example of a Web Form, showing a user searching with a Recipient ID, and the resulting search shows Recipient profile.
Searching for Outbound Recipient
Here the claim records that are being selected are part of a Loss Program coverage that provides reimbursement to employers for claims exceeding predetermined levels. This coverage type is purchased by employers who self-fund their employee benefit plan so that they don’t have to incur all of the liability for losses arising from a high medical claim.
Loss Program Claims selection
After data selection is completed, the next part of the Outbound transfer setup is to schedule the job so that the transaction runs based on a schedule defined by the business user. In the below screenshot of the sample Web Form, we are showing that the user selects when to run the transaction, transfer frequency, output data format (Flat File, XML, Fixed Width etc.), data mapping to convert source data into the format expected by the Recipient.
A sample Web Form for Operations to schedule an outbound Data Transfer to a Recipient
In Adeptia Connect, the location of Web Forms is organized under ‘My Solutions’ tab or as part of Dashboards. See below a screenshot of a form displayed under ‘My Solutions’ category.
Sample Web Forms in Adeptia Connect
Another view of a sample Web Form in Adeptia Connect
As part of your Outbound data transfer strategy, you can also let your Partners or Customers setup the outbound data transfers. By providing self-service capability to your clients you can offload much of the setup work from your business team and let your client users choose the type of data and when they want to receive that data from your system.